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Five simple steps to improve an emergency physician's efficiency
American Journal of Emergency Medicine (2008) 26, 1056–1063
www.elsevier.com/locate/ajem
Correspondence
Five simple steps to improve an emergency physician’s efficiency
To the Editor, Many areas of efficiency have been evaluated when attempting to improve flow in the emergency department (ED); however, the role of the physician if often overlooked. Here we present 5 simple steps that when implemented will enable providers to greatly improve their efficiency without changing their practice style. Despite the wide range in practice styles, these steps will help to increase productivity and potentially enhance patient care and rapport.
1. Step 1: identify why the patient is in the ED It is imperative to focus on why the patient is in the ED. It is easy to become distracted by the myriad of complaints that the patient verbalizes on presentation; however, it is imperative to focus on what the patient's potential medical emergency could be. Failure to focus on why the patient is in the ED can lead to a prolonged and unfocused evaluation. The physician must delineate the potential medical emergency and develop a clear plan to address it.
2. Step 2: establish a clear plan of care Having a well-thought-out plan is vital to streamlining the care of the patient. The provider should anticipate possible findings from the beginning of treatment to the final disposition. Having previously considered the potential findings will allow the physician to respond quickly when the results have returned. For the patient obviously requiring admission or discharge, order all necessary tests at the outset rather than in series. When the decision to admit or discharge is not immediately clear, it is imperative to identify what diagnostic test(s) need to be ordered or what response to treatment needs to be seen to answer the disposition question. There are many situations where a 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
computed tomography scan will be required to safely make a disposition. Not infrequently, patients wait several hours, with all prior tests complete, and then when trying to make a disposition the physician decides a computed tomography is needed and then orders it. All the necessary information to make that decision has been present but not acted on. Ordering time-consuming imaging studies should be done at the earliest possible moment and the results obtained promptly after completion.
3. Step 3: implement the plan of care Patient care in emergency medicine is a dynamic and interactive process. Updating and reevaluating the patient is a necessary and valuable tool. Evaluating the patient's response to treatment modalities will often help to clarify the ultimate disposition of the patient. When evaluating the response to a treatment, it is important to set time limits for each therapy and schedule reevaluations. This will prevent the prolonged emergency visit and the “forgotten” patient. A patient presenting with vomiting who is given fluids and an antiemetic or a patient with asthma who is given nebulizer therapy must be reevaluated frequently to see if their condition is improving, worsening, or remaining unchanged. The treatment and the plan should change accordingly. With each case, an end point should be predetermined. This keeps physicians focused and allows for a more efficient disposition. If a clear plan is not easily identifiable, stop and formulate a plan on how to arrive at a disposition point. All patients should have a well-thoughtthrough plan and a clear direction anticipating the possible findings. Not completing this thought process will lead to multiple patients with partial treatment plans leading to increased confusion and stress. Indecisiveness and disorganization substantially decreases provider efficiency.
4. Step 4: lead the team Coordinate the team to ensure all laboratory tests, radiographs, treatments, and consultations occur in the most
Correspondence
1057
efficient order. For example, have the β quantitative test running before ultrasound, start treatment with intravenous fluids and an antiemetic before x-ray, and start laboratory tests and treatment before sending the patient to radiology. This eliminates compounded waits. If results are not back or in process in a reasonable amount of time, find out why. Situations arise frequently where we are waiting for a test but the sample was never drawn, sent, processed, or placed into the computer.
5. Step 5: determine disposition After all of the information and results of treatment have been completed, determine a disposition on the patient. This sounds simple, but in a busy ED, the sense of urgency to see the next patient leads to many patients lacking final dispositions. Unless there is a critical patient, a disposition should be made before moving on to the next patient. Not doing this will lead to a partially completed patient unnecessarily occupying a bed with no active plan in place. Having multiple patients “in limbo” increases the workload of the entire ED staff. In conclusion, these basic steps can be used by any physician regardless of their practice style to safely and efficiently care for emergency patients.
Annie Sadosty MD Department of Emergency Medicine Mayo Clinic, Rochester, MN 55905, USA Brian Kruse MD Tyler Vadeboncoeur MD Department of Emergency Medicine Mayo Clinic, Jacksonville, FL 32224, USA E-mail address: [email protected] doi:10.1016/j.ajem.2007.11.004
To shock or not to shock In his review [1], Dr Stewart argues that the current prohibition on shocking apparent asystole in adults is not evidence-based. The question remains, however, how to investigate the issue. Dr Stewart mentions that it is left to the judgment of various automated external defibrillator (AED) manufacturers to distinguish fine ventricular fibrillation from apparent asystole based on amplitude and waveform. It might be an idea to study which brand of AEDs have the best survival rates. Do AEDs with a low amplitude threshold for shocking have more success? Although the answer to
this question does not fully solve the controversy, it would be a way to initiate research on this important matter. Peter Hallas MD Department of Anaesthesiology and Intensive Care Naestved Hospital Naestved, Denmark
doi:10.1016/j.ajem.2008.06.006
Reference [1] Stewart J. The prohibition on shocking apparent asystole: a history and critique of the argument. Am J Emerg Med 2008;26(5):618-22.
Is there an alternative to mouth-to-mouth breathing?
To the Editor, Is there an alternative to mouth-to-mouth breathing? In view of the present-day state of cardiopulmonary resuscitation (CPR), we believe it is time to rethink CPR. There is an increasing reluctance among untrained and trained rescuers, nurses, physicians, firemen, and policemen to perform mouth-to-mouth breathing if the victim is suspected of having an infectious disease [1-3]. In the poliomyelitis days of the 1950s, the iron lung and the cuirass provided ventilation for patents with respiratory paralysis. However, providing nursing care was difficult with the iron lung. It was less difficult with the cuirass respirator because the patient was in a wheelchair. However, an alternate method for ventilating polio patients was described by Eve [4] who used the rocking bed. Artificial respiration [5,6] was produced by rhythmic abdominal compression in polio patients by Adamson et al [7] and was later used by Miller et al [8] who described the device as the pneumobelt. In a recent 12-pig study by Pargett et al [9], ventilatory aspects of only abdominal compression CPR (OAC-CPR) [10] were determined. The ratio of tidal volume to respiratory dead space was 2.57 ± 0.4, indicating that the animals were well ventilated with only rhythmic abdominal compression, thereby eliminating the need for mouth-to-mouth breathing. In view of the fact that during ventricular fibrillation, OAC-CPR produces 1.60 ± 1.73 times more coronary perfusion than standard chest compression CPR in the same animals [10] and produces a tidal volume [9] 2.5 ± 0.4 times the respiratory dead space, it appears that this new CPR method merits further study [11,12]. Add to these benefits that OAC-CPR eliminates the need for
www.elsevier.com/locate/ajem
Correspondence
Five simple steps to improve an emergency physician’s efficiency
To the Editor, Many areas of efficiency have been evaluated when attempting to improve flow in the emergency department (ED); however, the role of the physician if often overlooked. Here we present 5 simple steps that when implemented will enable providers to greatly improve their efficiency without changing their practice style. Despite the wide range in practice styles, these steps will help to increase productivity and potentially enhance patient care and rapport.
1. Step 1: identify why the patient is in the ED It is imperative to focus on why the patient is in the ED. It is easy to become distracted by the myriad of complaints that the patient verbalizes on presentation; however, it is imperative to focus on what the patient's potential medical emergency could be. Failure to focus on why the patient is in the ED can lead to a prolonged and unfocused evaluation. The physician must delineate the potential medical emergency and develop a clear plan to address it.
2. Step 2: establish a clear plan of care Having a well-thought-out plan is vital to streamlining the care of the patient. The provider should anticipate possible findings from the beginning of treatment to the final disposition. Having previously considered the potential findings will allow the physician to respond quickly when the results have returned. For the patient obviously requiring admission or discharge, order all necessary tests at the outset rather than in series. When the decision to admit or discharge is not immediately clear, it is imperative to identify what diagnostic test(s) need to be ordered or what response to treatment needs to be seen to answer the disposition question. There are many situations where a 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
computed tomography scan will be required to safely make a disposition. Not infrequently, patients wait several hours, with all prior tests complete, and then when trying to make a disposition the physician decides a computed tomography is needed and then orders it. All the necessary information to make that decision has been present but not acted on. Ordering time-consuming imaging studies should be done at the earliest possible moment and the results obtained promptly after completion.
3. Step 3: implement the plan of care Patient care in emergency medicine is a dynamic and interactive process. Updating and reevaluating the patient is a necessary and valuable tool. Evaluating the patient's response to treatment modalities will often help to clarify the ultimate disposition of the patient. When evaluating the response to a treatment, it is important to set time limits for each therapy and schedule reevaluations. This will prevent the prolonged emergency visit and the “forgotten” patient. A patient presenting with vomiting who is given fluids and an antiemetic or a patient with asthma who is given nebulizer therapy must be reevaluated frequently to see if their condition is improving, worsening, or remaining unchanged. The treatment and the plan should change accordingly. With each case, an end point should be predetermined. This keeps physicians focused and allows for a more efficient disposition. If a clear plan is not easily identifiable, stop and formulate a plan on how to arrive at a disposition point. All patients should have a well-thoughtthrough plan and a clear direction anticipating the possible findings. Not completing this thought process will lead to multiple patients with partial treatment plans leading to increased confusion and stress. Indecisiveness and disorganization substantially decreases provider efficiency.
4. Step 4: lead the team Coordinate the team to ensure all laboratory tests, radiographs, treatments, and consultations occur in the most
Correspondence
1057
efficient order. For example, have the β quantitative test running before ultrasound, start treatment with intravenous fluids and an antiemetic before x-ray, and start laboratory tests and treatment before sending the patient to radiology. This eliminates compounded waits. If results are not back or in process in a reasonable amount of time, find out why. Situations arise frequently where we are waiting for a test but the sample was never drawn, sent, processed, or placed into the computer.
5. Step 5: determine disposition After all of the information and results of treatment have been completed, determine a disposition on the patient. This sounds simple, but in a busy ED, the sense of urgency to see the next patient leads to many patients lacking final dispositions. Unless there is a critical patient, a disposition should be made before moving on to the next patient. Not doing this will lead to a partially completed patient unnecessarily occupying a bed with no active plan in place. Having multiple patients “in limbo” increases the workload of the entire ED staff. In conclusion, these basic steps can be used by any physician regardless of their practice style to safely and efficiently care for emergency patients.
Annie Sadosty MD Department of Emergency Medicine Mayo Clinic, Rochester, MN 55905, USA Brian Kruse MD Tyler Vadeboncoeur MD Department of Emergency Medicine Mayo Clinic, Jacksonville, FL 32224, USA E-mail address: [email protected] doi:10.1016/j.ajem.2007.11.004
To shock or not to shock In his review [1], Dr Stewart argues that the current prohibition on shocking apparent asystole in adults is not evidence-based. The question remains, however, how to investigate the issue. Dr Stewart mentions that it is left to the judgment of various automated external defibrillator (AED) manufacturers to distinguish fine ventricular fibrillation from apparent asystole based on amplitude and waveform. It might be an idea to study which brand of AEDs have the best survival rates. Do AEDs with a low amplitude threshold for shocking have more success? Although the answer to
this question does not fully solve the controversy, it would be a way to initiate research on this important matter. Peter Hallas MD Department of Anaesthesiology and Intensive Care Naestved Hospital Naestved, Denmark
doi:10.1016/j.ajem.2008.06.006
Reference [1] Stewart J. The prohibition on shocking apparent asystole: a history and critique of the argument. Am J Emerg Med 2008;26(5):618-22.
Is there an alternative to mouth-to-mouth breathing?
To the Editor, Is there an alternative to mouth-to-mouth breathing? In view of the present-day state of cardiopulmonary resuscitation (CPR), we believe it is time to rethink CPR. There is an increasing reluctance among untrained and trained rescuers, nurses, physicians, firemen, and policemen to perform mouth-to-mouth breathing if the victim is suspected of having an infectious disease [1-3]. In the poliomyelitis days of the 1950s, the iron lung and the cuirass provided ventilation for patents with respiratory paralysis. However, providing nursing care was difficult with the iron lung. It was less difficult with the cuirass respirator because the patient was in a wheelchair. However, an alternate method for ventilating polio patients was described by Eve [4] who used the rocking bed. Artificial respiration [5,6] was produced by rhythmic abdominal compression in polio patients by Adamson et al [7] and was later used by Miller et al [8] who described the device as the pneumobelt. In a recent 12-pig study by Pargett et al [9], ventilatory aspects of only abdominal compression CPR (OAC-CPR) [10] were determined. The ratio of tidal volume to respiratory dead space was 2.57 ± 0.4, indicating that the animals were well ventilated with only rhythmic abdominal compression, thereby eliminating the need for mouth-to-mouth breathing. In view of the fact that during ventricular fibrillation, OAC-CPR produces 1.60 ± 1.73 times more coronary perfusion than standard chest compression CPR in the same animals [10] and produces a tidal volume [9] 2.5 ± 0.4 times the respiratory dead space, it appears that this new CPR method merits further study [11,12]. Add to these benefits that OAC-CPR eliminates the need for